Patient Signature (parent/guardian for minor) DATE. What is the reason for today s visit?
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- Beverly Snow
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1 I will truthfully answer all the following questions to the best of my knowledge. Spaces left blank will be understood (or interpreted) to mean NO or negative. Patient Signature (parent/guardian for minor) DATE What is the reason for today s visit? \ EYE HISTORY Glasses Contact Lenses Cataract Corneal problems Glaucoma Strabismus (crossed eyes) Retinal Detachment Eye Injury Macular Degeneration Diabetic retinopathy Laser Eye surgery Other eye surgery: MEDICAL HISTORY Diabetes, if so how long Cancer, if so what type High Blood Pressure HIV/AIDS VIH/SIDA Thyroid disease Anemia/Sickle Cell Migraine Sleep Apnea History of taking Flomax Use of steroids Raynaud s phenomenon Prior hemorrhage/blood transfusion Other medical history not listed above: SOCIAL HISTORY: > 16 year old Single Married I live alone I drive Alcohol use Marijuana use History of IV drug use Never Smoker Past Smoker, quit Current Smoker cigarettes/day SOCIAL HISTORY--<16 year old Lives with: Favorite activity: Grade in school: FAMILY HISTORY Eye problems (cataract, glaucoma, corneal problems, crossed eyes, macular degeneration): Diabetes High Blood Pressure Other family medical issues Page 1 of 5
2 Primary Care Physician/Address Referring physician /Address Last Eye Exam (Date/Doctor/Location) Preferred Pharmacy/Address/Phone Number PEDIATRICS ONLY FOR TESTING PURPOSES Immunizations up to date? Yes No Height Premature birth? Yes No Weight Birth weight Metal in body? Gestational age ALLERGIES Allergies already documented in Cerner No allergies Latex allergy Allergy Reaction MEDICATIONS Medications already documented in Cerner Medication list attached No medications Medication name Dose How Often Last dose Date/Time Page 2 of 5
3 Refraction (Exam for glasses) Your medical insurance usually covers an eye examination based on your visual complaints and a medical diagnosis. However, very few medical insurance plans cover a refraction to determine whether your vision can be improved with glasses. A refraction is used as a medical tool to help determine if there is any vision loss and whether or not it is related to a medical condition. We will bill your insurance $25.00 for this service. However, if it is not covered by your insurance, you will be responsible for payment. I have read the above information and understand that refraction is a noncovered service. I accept full financial responsibility for the cost of this service. My co-payment is separate from and not included in the refraction fee. This notice is good for one year from the date signed. Patient Signature (parent/guardian for minor) Date Page 3 of 5
4 ADULT If the patient is 18 years of age or older, please fill out the following. General Health excessive weight loss/gain change in appetite fevers /chills excessive sweating weakness/fatigue Other Head/Ear/Nose/Throat headaches hearing problems ringing in ears ear infections or pain vertigo/diziness tooth ache/dental problems bleeding from the gums or nose throat pain/difficulty swallowing Respiratory/Breathing Problems cough wheezing/asthma cough producing sputum or blood frequent colds/cough Cardiovascular System high blood pressure fainting ankle/leg swelling palpitations or rapid heart beat heart mumur heart attack difficulty breathing when lying flat rheumatic fever chest pain Other: Gastrointestinal excessive nausea/vomiting blood in the stools or dark tarry stools change in bowel habits Other: Genital/Urinary pain with urination frequent urination blood in the urine discharge or sores in the genital area Musculoskeletal arthritis joint pains _ Skin rashes /hives easy bruising Neurological/Psychiatric weakness/numbness on one side of the body seizures loss of consciousness or stroke psychiatric problems depression _ Endocrine unsual heat or cold sensitivity change in voice/hair diabetes Page 4 of 5
5 : : PEDIATRIC For patients under 18 years of age, please fill out the following and write any explanations in the space provided. YES NO Birth History Gastrointestinal the patient was born premature full term pregnancy complications? Other: General Health excessive weight loss/gain change in appetite fevers /chills weakness/fatigue Head/Ear/Nose/Throat headaches hearing problems ear infections or pain bleeding from the gums or nose teeth problems Respiratory/Breathing Problems cough wheezing/asthma frequent colds/cough Neurological/Developmental Attention deficit disorder behavioral problems seizures developmental delay speech difficulties reading difficulties/delays Does the child receive therapy? PT OT speech therapy vision therapy Other: Yes No Has your child ever been hospitalized? If yes,explain frequent nausea/vomiting diarrhea /constipation abdominal pain bloody bowel movements Other: Genital/Urinary frequent urination blood in the urine urinary infection Musculoskeletal muscle pains joint pains abnormal walking curved spine (scoliosis) broken bones swollen glands twisting of the neck (torticollis) _ Skin rashes /hives easy bruising Cardiovascular System shortness of breath or difficulty breathing irregular or fast heart beat fainting spells of turning blue (Cyanosis) Contagious Diseases: during the last 30 days has your child been exposed to any contagious disease (measles, chicken pox, etc.)? No Yes If yes, list: Page 5 of 5
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Rehabilitation Medicine Clinic. New Patient Questionnaire
Rehabilitation Medicine Clinic (Please complete this 5-page form and bring to your appointment.) Date Appt. Date Age Date of Birth Name Male Female Hand dominance: R L Home Address Home Phone ( ) Work
NURSING STUDENT HEALTH & IMMUNIZATION RECORDS
NURSING STUDENT HEALTH & IMMUNIZATION RECORDS *********************************** COMPLETE THE ATTACHED HEALTH PACKET AND SUBMIT TO THE NURSING DEPARTMENT NO LATER THAN THE ASN ORIENTATION. **************************************
Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527
Jerry Drucker, MD, FACE The Endocrine Center of Florida, LLC Board Certified Internal Medicine 34041 US Highway 19 North, Suite C Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD DATE PATIENT INFORMATION OUR DOCTOR CHART NO. LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN NAME Are you
Name Home phone Work phone. Address. Email address. Date of birth Gender (circle): M F Marital status No. of children. Name of partner Referred by
Name Home phone Work phone Address Email address Date of birth Gender (circle): M F Marital status No. of children Name of partner Referred by Have you ever seen a Chiropractor? No Yes (Who?): Insurance
RETINA CARE CENTER, P.C. PATIENT INFORMATION
RETINA CARE CENTER, P.C. JONATHAN M. BAROFSKY, M.D., F.A.C.S. Parkway Seventy Plaza 1255 Route 70, Suite 31N Lakewood, New Jersey 08701 PHONE (732)905 0004 FAX (732)905 3868 PATIENT INFORMATION Welcome
Relation Address City State Zip Code
To enable us to provide you with the best possible care, please complete the following: Date: Name Social Security # First Full Middle Last Address City Zip Code_ Telephone (home) (work) Date of Birth
Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute
NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:
ORANGE COUNTY EYE INSTITUTE
ORANGE COUNTY EYE INSTITUTE *Note: It is the patient s responsibility to file insurance claims if we are not contracted with your insurance company. *Note: Be aware that most medical insurance plans do
INITIAL PATIENT QUESTIONNAIRE-
Date: Patient Address: Home Phone: Work Phone: Age: Height: cm/inches Weight: kg/lbs Male Female Referring Physician s Name: Physician Phone: Physician Address: Type of Practice (Internist, Surgeon, etc.):